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Pneumococcal Vaccine Playbook: Calling an Audible 13, 15, 20, and or 23
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Just in case you “aren’t from around here”, the state of Alabama is very divided when it comes to college football. In general, you are either a devoted fan of the Alabama Crimson Tide or the Auburn Tigers. On a personal note, and having been told I was from up North (Tennessee), I root for the Tennessee Vols. Unlike the either or of college football, receiving the COVID-19 vaccine, your annual flu shot, and pneumococcal vaccinations are integral to your personal preventive healthcare playbook.

Did You Know?

According to the CDC, “pneumococcal disease is common in young children, but older adults are at greatest risk of serious illness and death.” Potential “defensive options” have been made available by the FDA approval of five different pneumococcal vaccines.

Prevnar® or PCV7 was the first pneumococcal conjugate vaccine licensed by the FDA in 2000. This vaccine provided protection against seven types of pneumococcal bacteria.

Prevnar 13® (pneumococcal conjugate vaccine or PCV13) is a registered trademark by Wyeth LLC and marketed by Pfizer Inc. This vaccine provides protection against infections caused by 6 more serotypes than PCV7. This vaccine is part of the routine childhood immunization schedule. Additionally, in 2011, it was licensed by the FDA for use in adults 50 years or older. The CDC recommends PCV13 for:

  • All children younger than 2 years old, and
  • People 2 years or older with certain medical conditions. The CDC advises adults 65 years and older to discuss the need for this vaccine with their health care provider.

Pneumovax23® (pneumococcal polysaccharide vaccine or PPSV23) is a Merck product This vaccine was approved by the FDA in 1983 and helps protect against 23 types of pneumococcal bacteria. The CDC recommends this vaccine for:

  • All adults 65 years or older,
  • People 2 through 64 years old with certain medical conditions (i.e., diabetes, heart disease or COPD), and
  • Adults 19 through 64 years old who smoke cigarettes.

Prevnar 20™ (Pneumococcal 20-valent Conjugate Vaccine) On June 8, 2021, Pfizer announced (link) the FDA approval of the Prevnar 20™ vaccine for adults 18 years or older and noted that it is “the first approval of a conjugate vaccine that helps protect against 20 serotypes responsible for the majority of invasive pneumococcal disease and pneumonia, including seven responsible for 40% of pneumococcal disease cases and deaths in the U.S.”

Vaxneuvance™ (Pneumococcal 15-valent Conjugate Vaccine) On July 16, 2021, Merck announced (link) the FDA approval of Vaxneuvance™, a new vaccine for the prevention of invasive pneumococcal disease in adults 18 years and older caused by 15 serotypes.

Why It Matters?

With the approval of new vaccines, Medicare has expanded their coverage.

Medicare Coverage of Pneumococcal Vaccines

You can find information about pneumococcal shot and administration in the Medicare Learning Network Educational Tool: Medicare Preventive Services (link). This resource was last updated in September 2021 and indicates that Medicare will cover all patients with no copayment, coinsurance, or deductible for the Prevnar 13® and Pneumovax23® vaccines.

Since September, CMS published the following information related to the Prevnar 20™ Vaccine in the Thursday, October 14, 2021 edition of MLN Connects (link):

“Medicare began covering Pneumococcal conjugate vaccine, 20 valent on October 1. CMS suggests submitting separate claims for this vaccine (HCPCS code 90677).

  • Part A Medicare Administrative Contractors (MACs) will hold these claims until the April 2022 system update
  • Part B MACs began processing these claims on October 4
  • CMS will deny claims for vaccines provided July 1–September 30 (before it was covered by Medicare)”

The CMS has also released Transmittal 11092 (Change Request 12439) and related MLN Matters Article (link) providing claims processing instructions for the new Pneumococcal conjugate vaccine, 20 valent.

What Can You Do?

With the 2021 approval of two new pneumococcal vaccines, the CDC’s Advisory Committee on Immunization Practices (ACIP) has held meetings to discuss considerations for age-based and risk-based use of PCV 15/PCV 20 among adults. The most recent meeting was a couple of weeks ago now on October 20, 2021 (link).

As a healthcare provider, I recommend “scouting” for Medicare guidance related to coverage of the Vaxneuvance™ vaccine. As a healthcare consumer, talk with your physician to come up with the winning play for your vaccination needs.


Beth Cobb

Trick or Treat: FY 2022 Hospital Readmission Reduction Program Penalties
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 | Coding 
 | Quality 

Even though, Halloween has come and gone, the shift in your Hospital Readmission Reduction Program penalty for the new CMS Fiscal Year may or may not be a treat.

Did You Know?

It has been a decade since CMS began reducing payments to hospitals for excessive readmissions. The payment reduction is capped at 3 percent (that is, a payment adjustment factor of 0.97). And while your penalty rate is based on unplanned readmissions for the following six conditions, the penalty is applied to all Medicare Fee-for-Service inpatient discharges:

  • Acute myocardial infarction (MI),
  • Chronic Obstructive Pulmonary Disease (COPD),
  • Heart Failure (HF),
  • Pneumonia,
  • Coronary Artery Bypass Graft (CABG) surgery, and
  • Elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA).

The CMS unplanned hospital visits provider data was last updated September 22, 2021 and released on October 27, 2021 (link). Note, data for the first and second quarters of 2020 are not included in this release due to the impact of the COVID-19 pandemic. CMS has updated the Medicare Hospital Compare webpage (link) with the latest data release.

Why it Matters?

FY 2022 Readmission Reduction Penalties by the Numbers According to a Kaiser Health News article by Jordan Rau (link):

  • 2,499 or 47% of all hospitals will be receiving reduced payments,
  • The average penalty is a 0.64% reduction in payment,
  • Congress’ Medicare Payment Advisory Commission (MedPAC) has noted that the average fines for a hospital in 2018 was $217,000.
  • For FY 2022, 82% of hospitals will receive a penalty. This is nearly the same number of hospitals as last year.

What Can You Do?

I encourage you to read the Kaiser Health News article and access the accompanying Look-Up Tool (link) where you will find a trend of your hospitals Readmission Penalties from FY 2015 through 2022.

Beth Cobb

October 2021 Medicare Education and COVID-19 Updates
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Medicare Educational Resources

MLN Booklet: Transitional Care Management Services Revised

This MLN Booklet (link) focuses on covered services, location, who may provide services, supervision, billing services, documenting services and service benefits specific to Transitional Care Management. With the most recent updates, the CMS has added codes health care professionals can bill concurrently with Transitional Care Management services and added language about auxiliary personnel providing services under supervision.

WPS GHA YouTube: CERT Errors – Transitional Care Management (TCM)

WPS has published a YouTube video (link) focused on two Comprehensive Error Rate Testing (CERT) errors on Transitional Care Management (TCM) services. The errors concern the patient record for the:

  • Medical decision-making complexity
  • Interactive contact
MLN Booklet: Medicare Mental Health (MLN1986542)

This MLN booklet (link) was updated this month and includes information on covered and non-covered services, eligible professionals, Medicare Advantage and Medicare drug plan coverage, and medical record documentation and coding guidance.

COVID-19 Updates

COVID-19 Booster Shots for Eligible Consumers

From late September to mid-October, there have been several updates related to COVID-19 booster shots, for example:

  • September 24, 2021: CMS to Pay for COVID-19 Booster Shots: (link)
  • FDA Bulletin Announcing Booster Shot Authorization: (link)
  • September 28, 2021: CDC Call: What Clinicians Need to Know About the Latest CDC Recommendations for Pfizer-BioNTech COVID-19 Booster Vaccination: (link)
  • October 7, 2021: CDC Guidance: Who is Eligible for a COVID-19 Booster Shot? (link)
  • October 20, 2021: FDA Takes Additional Actions on the Use of a Booster Dose: (link)
  • October 21, 2021: CDC Expands Eligibility for COVID-19 Booster Shots: (link)
  • October 22, 2021: CMS Reminds Eligible Consumers They Have Coverage for COVID-19 Booster Shot as No Cost: (link)
  • October 26, 2021: CDC Clinician Outreach Call – What Clinician’s Need to Know About COVID-19 Booster Recommendations: (link)
September 30, 2021: OCR Issues Guidance on HIPAA, COVID-19 Vaccinations, and the Workplace

HHS and the Office of Civil Rights (OCR) announced their release of guidance (link) to help the public understand when the HIPAA Privacy Rule applies to information about a person’s COVID-19 vaccination status. The “guidance addresses common workplace scenarios and answers questions about whether and how the HIPAA Privacy Rule applies.”

October 5, 2021: Getting Your CDC COVID-19 Vaccination Record Card

The CDC has updated their webpage Getting Your CDC COVID-19 Vaccination Record Card (link). Of note, the “CDC does not maintain vaccination records or determine how vaccination records are used, and CDC does not provide the white CDC-labeled COVID-19 Vaccination Record card to people. These cards are distributed to vaccination providers by state health departments.” The CDC advises you to contact your state health departments if you have additional questions about your vaccination records. This webpage includes a link to help you find information about your state health department.

October 15, 2021: COVID-19 Public Health Emergency (PHE) Extended

Xavier Becerra, Secretary of Health and Human Services, renewed the Public Health Emergency (PHE) due to the COVID-19 pandemic (link). This declaration will last for the duration of the emergency or 90 days and may be extended again by the Secretary. Continuation of the PHE means that 1135 Blanket Waivers for health care providers will remain in place too (link).

Other Updates

September 30, 2021: Requirements Related to Surprise Billing; Part II

The CMS announced the issuance of an interim final rule with comment period to further implement the No Surprises Act (link). In addition to this second interim final rule, CMS launched new online information at In this Fact Sheet, CMS reminds you that the rules will take effect on January 1, 2022 and that “more information on how the rule impacts various types of health plans, providers, and organizations supporting payment dispute processes is described in a related fact sheet (link).

October 10, 2021: MLN Connects – Drugs & Biologics

CMS noted in the October 10th edition of MLN Connects (link) that they have published the third quarter 2021 HCPCS Application Summaries and Coding Decisions for Drugs and Biologics. Of the fourteen requests to establish a new HCPCS Level II code, eight new codes were established with an effective date of January 1, 2022.

Beth Cobb

October 2021 Medicare Transmittals and Coverage Updates
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 | Coding 

Medicare MLN Articles & Transmittals – Recurring Updates

January 2022 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Fields and Revisions to Prior Quarterly Pricing Files
  • Article Release Date: October 1, 2021
  • What You Need to Know: Billing staff need to be aware of these quarterly updates to Medicare ASP and Not Otherwise Classified (NOC) Part B drug pricing files.
  • MLN MM12469: (link)
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 28.0, Effective January 1, 2022
  • Article Release Date: October 1, 2021
  • What You Need to Know: Billing staff need to be aware of these quarterly updates to Medicare ASP and Not Otherwise Classified (NOC) Part B drug pricing files.
  • MLN MM12469: (link)
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2022
  • Article Release Date: October 1, 2021
  • What You Need to Know: Billing staff need to be aware of these quarterly updates to Medicare ASP and Not Otherwise Classified (NOC) Part B drug pricing files.
  • MLN MM12469: (link)
New/Modifications to the Place of Service (POS) Codes for Telehealth
  • Article Release Date: October 14, 2021
  • What You Need to Know: The POS Workgroup has revised the description of existing POS code 2 and added a new POS code 10.
  • MLN MM12427: (link)
Claim Status Category and Claim Status Codes Update
  • Article Release Date: October 14, 2021
  • What You Need to Know: This article updates, as needed, the Claims Status and Claim Status Category Codes approved by the National Code Maintenance Committee.
  • MLN MM12299: (link)
April 2022 Update to the Java Medicare Code Editor (MCE) for New Edit 20 – Unspecified Code Edit
  • Article Release Date: October 22, 2021
  • What You Need to Know: This article tells about system changes needed to update the MCE to accept a new MCE edit 20 (Unspecified Code Edit).
  • MLN MM12471: (link)

Revised Medicare MLN Articles & Transmittals

Medicare Clarifies Recognition of Interstate License Compact Pathways
  • Article Release Date: Initial article May 5, 2020 – Revision September 16, 2021
  • What You Need to Know: The CMS revised this MLN article to clarify recognition of licenses through interstate license compact pathways as valid and full licenses for purposes of meeting federal license requirements.
  • MLN SE20008: (link)
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2022
  • Article Release Date: August 12, 2021 – Revised October 6, 2021
  • What You Need to Know: This MLN article was revised to reflect revised CR 12417 which corrected the fixed dollar loss threshold amount to $16,040.
  • MLN MM12417: (link)
National Coverage Determination (NCD 110.24): Chimeric Antigen Receptor (CAR) T-cell Therapy – This CR Rescinds and Fully Replaced CR 11783
  • Article Release Date: May 24, 2021 – Revised October 6, 2021
  • What You Need to Know: In this fourth iteration of this MLN article, information has been added on the use of the KX modifier on professional claims. Substantive changes are in dark red font.
  • MLN MM12177: (link)

Medicare Coverage Updates

September 27, 2021: Final Decision Memo – Home Use of Oxygen and Home Oxygen to Treat Cluster Headaches

The CMS posted a final national coverage determination (NCD) and decision memo ((link) for two separate, but medically related NCDs.

  • NCD 240.2.2: Home Oxygen Use to Treat Cluster Headaches (CH)
    • CMS is removing this NCD from the Medicare NCD manual,
    • Ending Coverage with Evidence Development (CED), and
    • Allowing MACs to make coverage determinations regarding the use of home oxygen and oxygen equipment for CH.
  • NCD 240.2: Home Use of Oxygen
    • CMS is expanding patient access to oxygen and oxygen equipment in the home, and
    • Permitting MACs to cover the use of home oxygen and oxygen equipment in order to treat CH and other acute conditions.

Beth Cobb

OIG Overpaid $636 Million for Neurostimulator Implantation Surgeries
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 | Coding 
 | OIG 

I have recently noticed a resurgence of a favorite commercial from my childhood featuring a little boy, Mr. Turtle, Mr. Owl, and a tootsie roll pop (link). Although it’s a given that we will never know how many licks it takes to get to the center of a Tootsie Roll pop, it’s no mystery as to why the OIG believes CMS has paid millions in overpayments for neurostimulator implantation surgeries. Let’s unwrap this OIG report (link) and get to the center of it.

Why This Audit was Conducted

CMS analysis revealed that claims for spinal neurostimulator implantation surgeries increased by nearly 175 percent between 2007 and 2018. “CMS researched possible causes for the increased volume of these procedures that would indicate the services are increasingly necessary, but CMS did not find any plausible reason for the increase in services and concluded that a financial motivation was the most likely cause for the increase.”

Strategic Health Solutions, the first Supplemental Medical Review Contractor (SMRC), was tasked with reviewing post-payment claims of Medicare Part B spinal neurostimulator implantation surgeries. They reviewed claims with dates of service from January through September of 2014 and identified a 72% error rate.

Without a “plausible reason for the increase in services” and the SMRC review’s high error rate, the OIG conducted this review to “determine whether health care providers complied with Medicare requirements when they billed for neurostimulator implantation surgeries.”

What are Neurostimulators?
  • What is it? A battery-powered electronic device enclosed in a small metal container that is surgically implanted under a patient’s skin and connected to wires called leads
  • Types of Neurostimulators: Spinal cord, deep brain, and vagus nerve stimulator (VNS) devices.
  • Conditions that can be treated with neurostimulator: chronic pain, Parkinson’s disease, essential tremor, dystonia, obsessive-compulsive disorder, seizures, and epilepsy.
Medicare Coverage Requirements for Neurostimulators

As noted above, there are several conditions where treatment with a neurostimulator implant may be warranted. Medicare has several National Coverage Determinations (NCDs) related to neurostimulators that detail the indications and limitations of coverage, including:

  • NCD 160.2: Treatment of Motor Function Disorders with Electrical Nerve Stimulation,
  • NCD 160.7: Electrical Nerve Stimulators,
  • NCD 160.18 – Vagus Nerve Stimulation, and
  • NCD 160.24 – Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease.
OIG Claims Selection by the Numbers
  • 2016-2017: The audit period for this review,
  • $1.4 billion: The Medicare payments made to providers during the audit period,
  • 58,213: The number of beneficiaries who had at least one neurostimulator implantation during the audit period.
  • HCPCS Codes 61885, 61886, or 63685: The codes used to identify beneficiaries who had undergone a neurostimulator implantation surgery.
  • 124 claims: The stratified random sample of claims reviewed in this audit.
  • $1,000: All claims reviewed were for paid amounts greater than $1,000.
  • $3.4 million: The amount paid to 102 providers for the 124 claims in the audit sample.
  • Audit sample claim specific indication for neurostimulator:
    • 87 claims were for treatment of chronic pain,
    • 4 claims were for treatment of seizures, and
    • 13 claims were for essential tremors and Parkinson’s disease.
    • Note, the remaining two claims involved a neurostimulator implant with an investigational device exemption.
Audit Error Rates

The OIG found that 40% of health care provided did not comply with Medicare requirements. Based in this finding, they estimated that:

  • Providers received $636 million in unallowable Medicare payments, and
  • Medicare beneficiaries paid $54 million in related unnecessary coinsurance amounts.

An independent contractor reviewed the medical records and determined that 48 (49%) of the 106 claims did not contain documentation supporting compliance with the applicable NCD indications. The OIG report lists types of missing/incomplete documentation by NCD, for example:

  • NCD 160.7:
    • No documentation of other failed treatment modalities or that other treatment prior to a neurostimulator was felt to be unsuitable or contraindicated, and
    • No documentation of the multidisciplinary screening includes a psychological evaluation.
OIG Audit Conclusions & Recommendations

The “tootsie-roll center” of this audit are the OIG’s audit conclusions and recommendations. Both lay the groundwork for steps for providers moving forward. The OIG concluded that:

  • Medical records lacked documentation to support the NCD coverage requirements for neurostimulator implants,
  • There were limited instances when providers “stated that they did not fully understand these Medicare coverage requirements,”
  • These claims did not require prior authorization, nor were they subject to pre-payment reviews, and
  • There is no edit in the CMS software to initiate such a review.
  • It was not until after the completion of this audit that CMS published the CY 2021 OPPS Final Rule that added prior authorization of spinal neurostimulators to the Prior Authorization for Certain Hospital Outpatient Department Services program effective for services on or after July 1, 2021(link). The OIG notes that this final rule does not include claims for neurostimulator implantation for Parkinson’s disease or seizure disorders.
    • Note, in May of 2021, the CMS limited the prior authorization requirement to CPT code 63650 (implantation of spinal neurostimulator electrodes, accessed through the skin).

Based on their conclusions, the OIG recommended that CMS instruct the Medicare Administrative Contractors:

  • Recover overpayments,
  • Advise applicable providers to exercise reasonable diligence to identify, report, and return over-payments in accordance with the 60-day rule,
  • Conduct provider outreach and education regarding Medicare coverage requirements, and
  • Require prior authorization for procedures for Parkinson’s disease and seizures.

CMS agreed with all recommendations but indicated that neurostimulator implantation for Parkinson’s disease and seizure disorders are currently on the Medicare Inpatient Only (IPO) Procedure List and their prior authorization authority does not extend to inpatient services. The OIG noted that “CMS’s inability to implement this control for inpatient claims…leaves this area vulnerable to future overpayments.”

Steps Moving Forward

I encourage you to:

  • Become familiar with the Medicare coverage requirements at the National and Local MAC level,
  • Identify the documentation deficiencies by NCD detailed in this OIG report,
  • Work with your Physician’s offices to ensure all documentation needed to support the medical necessity of the procedure is in the medical record, and
  • Learn about current MAC specific provider outreach and education activities in a related article in this week’s newsletter.

Beth Cobb

October 2021 P.A.R. Pro Tips: Neurostimulator Implantation Surgeries
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 | Billing 
 | Coding 
 | OIG 

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e. MAC, RAC, OIG, etc.) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities in this P.A.R. Pro Tips article. This month’s focus is on neurostimulator implantation surgeries.

Did You Know?

Effective for services on or after July 1, 2021, implanted spinal neurostimulator procedures was one of two new procedures added to the list of procedures included in the Prior Authorization for Certain Hospital Outpatient Department (OPD) Services program (">link).

On October 5, 2021, the Office of Inspector General released the report Medicare Overpaid More Than $636 Million for Neurostimulator Implantation Surgeries (link). The OIG made several recommendations to CMS in response to the review findings. One recommendation being that MACs conduct provider outreach and education.

Pro Tip: MAC Neurostimulation Implantation Surgery Provider Outreach and Education Efforts

In response to neurostimulation implantation being added to the Prior Authorization for Certain OPD Services program and to recommendations made by the OIG in their report, the MACs have been conducting provider outreach and education. This article highlights resources available by the different MACs. You can read more about the OIG report in a related article in this week’s newsletter.

CGS (Jurisdiction 15)

The CGS OPD Prior Authorization webpage (link) includes medical record documentation needed to meet coverage criteria for all procedures in this program including implanted spinal neurostimulators.

First Coast Service Options, Inc. (Jurisdiction N)

First Coast published the article Implantation of spinal neurostimulator in their October 13, 2021, First Coast eNews article (link).

You can also find general documentation requirements and links to Local Coverage Determination (LCD) and Local Coverage Article (LCA) for Spinal Cord Stimulation for Chronic Pain on their PA Program general documentation requirements webpage (link).

National Government Services (J6 and JK MAC)

In July, NGS posted a news article (link) to their website highlighting information about prior authorization for implanted spinal neurostimulators including:

  • The applicable HCPCS code,
  • Documentation Requirements, and
  • Links to related content.

You will find a link to the required coversheet to request prior authorization for performing an implanted spinal neurostimulator procedure and National Coverage Determination (NCD) 160.7 Electrical Nerve Stimulators on the NGS Prior Authorization Documentation webpage (link) includes a

Noridian (JE and JF MAC)

Both Noridian JE (link) and Noridian JF (link) have an article posted under Medical Review on their website, that provides general documentation requirements and links to their LCD and LCA for Spinal Cord Stimulators for Chronic Pain.

Novitas Solutions Jurisdiction (JH and JL MAC)

Novitas recently published the article Prior Authorization: Implantation of Spinal Neurostimulator in (link), highlighting the components of the spinal cord neurostimulator system, documentation requirements, best practice documentation feedback/tips and links to related content including their LCD and LCA titled Spinal Cord Stimulation.

In July 2021, Novitas updated their Prior Authorization Program for certain hospital outpatient department services general documentation requirements article to include guidance for implanted spinal neurostimulators (trial or permanent) and cervical fusion with disc removal (link).

Finally, in case you missed it, you can view a September 8, 2021 webinar (link) recording focused on reviewing the two new services requiring PA effective dates of service on and after July 1, 2021.

Palmetto GBA (JJ and JM MAC)

On October 12, 2021, Palmetto GBA updated their article titled Implantation of Spinal Neurostimulator. You can find this article on their Outpatient Department Prior Authorization (PA) webpage (link). Additional resources available on the Palmetto website includes:

  • A Documentation Checklist (link) highlighting the documentation requirements for trial or permanent implanted spinal neurostimulators,
  • An on-demand webinar video (link) highlighting the two services added to Outpatient PA program effective July 1, 2021 (implanted spinal neurostimulators and cervical fusion with disc removal), and an
  • Links LCD (L37632) and LCA (A56876) for Spinal Cord Stimulators for Chronic Pain (link).

WPS (J5 and J8 MAC)

WPS has published an article (link) highlighting the July 1, 2021 addition of implanted spinal neurostimulators to the hospital outpatient department Prior Authorization Program.

On August 18, 2021, WPS posted a YouTube video (link) detailing the process for submitting a prior authorization request for implanted spinal neurostimulators.

WPS also has a live event scheduled for October 26, 2021, titled Prior Authorization – Understanding Implanted Spinal Neurostimulators in the Hospital Outpatient Department (">link). They note in the announcement that this teleconference will answer questions on:

  • Inpatient Psychiatric Facility (IPF),
  • Inpatient Rehabilitation Services,
  • Routine Foot Care, and
  • Wound care in a Critical Access Hospital (CAH).

What Can You Do?

Take advantage of resources made available by your MAC related to implanted spinal neurostimulators.

Beth Cobb

Billing a Screening Mammography that Becomes a Diagnostic Mammography
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 | FAQ 

How do we bill mammography services when a beneficiary undergoes a screening and diagnostic mammogram on the same day?


According to the MLN educational tool: Medicare Preventive Services (, “if you perform and bill a screening mammogram and a diagnostic mammogram on the same day, use modifier -GG to show a screening mammography turned into a diagnostic mammography.”

Beth Cobb

Happy Case Management Week 2021
Published on 


 | Coding 

This week is National Case Management Week. Given the ongoing COVID-19 public health emergency (PHE), now more than ever it is important to celebrate the hard work and dedication of Case Managers. The American Case Management Association (ACMA) and the Case Management Society of America (CMSA) both recognize this week as an opportunity to spotlight the great things about case managers and the case management industry.

American Case Management Association (ACMA)

The ACMA’s official definition of Case Management, as approved by their membership in April 2020, as follows:

"Case Management in health care delivery systems is a collaborative practice including patients, caregivers, nurses, social workers, physicians, payers, support staff, other practitioners and the community. The Case Management process facilitates communication and care coordination along a continuum through effective transitional care management. Recognizing the patient’s right to self-determination, the significance of the social determinants of health and the complexities of care, the goals of Case Management include the achievement of optimal health, access to services, and appropriate utilization of resources."

For 2021, the ACMA Case Management Week theme is Case Management: Transitions through Care, Compassion, Community. MMP believes it takes all three qualities to carry out the definition of Case Management and would like to celebrate the hard work and dedication of all the Case Managers that we have the opportunity to work with.

Beth Cobb

Final Rules, Quarterly Updates and Coding Guidance Effective October 1, 2021
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Monthly, MMP includes a “Medicare Updates” article at the end of the month. With the October 1st start of the CMS FY 2022, as well as quarterly outpatient updates, this special edition “Medicare Updates” article highlights guidance effective October 1, 2021.

October 2021 Prospective Payment System Final Rules

FY 2022 Hospital IPPS and Long-Term Care Hospital (LTCH) Rates Final Rule (CMS-1752-F)

  • CMS Fact Sheet: (link)
  • FY 2022 IPPS Final Rule Home Page: (link)

FY 2022 Inpatient Psychiatric Facility (IPF) PPS Final Rule (CMS-1750-F)

  • CMS Fact Sheet: (link)

FY 2022 Inpatient Rehabilitation Facility (IRF) PPS Final Rule (CMS-1748-F)

  • CMS Fact Sheet: (link)

FY 2022 Skilled Nursing Facility (SNF) PPS Final Rule (CMS-1746-F)

  • CMS Fact Sheet: (link)

FY 2022 Hospice Payment Rate Update Final Rule (CMS-1754-F)

  • CMS Fact Sheet: (link)
Medicare Change Requests (CRs) & MLN Articles

Quarterly Update to the End-Stage Renal Disease Prospective Payment System (ESRD PPS)

  • Article Release Date: September 24, 2021
  • What You Need to Know: Article includes updates to diagnosis codes eligible for the ESRD PPS co-morbidity payment adjustment.
  • CR 12307 & MM12307: (link)

October 2021 Integrated Outpatient Code Editor (I/OCE) Specifications Version 22.3

  • Article Release Date: September 22, 2021
  • What You Need to Know: Article details claims processing changes for hospital outpatient departments, community mental health centers, all non-OPPS hospital providers, limited services when provided in a home health agency not under the HH PPS, and a hospice patient for the treatment of a non-terminal illness.
  • CR 12432 & MM12432: (link)

October Quarterly Update for 2021 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

  • Article Release Date: September 21, 2021
  • What You Need to Know: DMEPOS fee schedule changes include changes related to the COVID-19 Aid, Relief, and Economic Security (CARES) Act, 2020.
  • CR 12453 & MM12453: (link)

October 2021 Update to the Hospital Outpatient Prospective Payment System (OPPS)

  • Article Release Date: September 21, 2021
  • What You Need to Know: Article includes three updates related to new COVID-19 codes.
  • CR 12436 & MM12436: (link)

October 2021 Update of the Ambulatory Surgical Center (ASC) Payment System

  • Article Release Date: September 17, 2021
  • What You Need to Know: Article reviews changes in the October 2021 ASC payment system update.
  • CR 12451 & MM12451: (link)

Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Subject to Reasonable Charge Payment

  • Article Release Date: September 10, 2021
  • What You Need to Know: Article provides a link to new proprietary laboratory analysis (PLAs) codes.
  • CR 12435 & MM12435: (link)

Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for FY 2022

  • Article Release Date: August 12, 2021
  • What You Need to Know: Article includes information regarding rate updates.
  • CR 12364 & MM12364: (link)

Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update for FY 2022

  • Article Release Date: August 10, 2021
  • What You Need to Know: CR 12366 issued official instruction to the MACs for the FY 2022 SNF payment rate updates.
  • CR 12366 & MM12366: (link)

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2021 Update

  • Article Release Date: August 9, 2021
  • What You Need to Know: This article includes coding updates. CMS notes “MACs won’t search their files to retract payment for claims that are already paid or to retroactively pay claims impacted by these changes. However, they will adjust claims you bring to their attention.”
  • CR 12422 & MM12422: (link)

Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2022

  • Article Release Date: August 5, 2021
  • What You Need to Know: Article includes payment rates, wage index and Pricer updates.
  • CR 12354 & MM12354: (link)

October 2021 Quarterly Average Sale Price (ASP) Medicare Part B Drug Pricing Files and Revision to Prior Quarterly Pricing Files

  • Article Release Date: July 15, 2021
  • What You Need to Know: Article details information about the ASP methodology, which is based on quarterly data manufacturers submit to the CMS.
  • CR 12342 & MM12342: (link)

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 27.3, Effective October 1, 2021

  • Article Release Date: July 14, 2021
  • What You Need to Know: Recurring updates applies to the Medicare Claims Processing Manual (Publication 100-04), Chapter 23, section 20.9.
  • CR 12340 & MM12340: (link)

nternational Classifications of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations – October 2021

  • Article Release Date: May 27, 2021
  • What You Need to Know: Article provides updates due to newly available codes, separate NCD coding revisions and coding feedback received.
  • CR 12279 & MM12279: (link)
FY 2022 Coding Guidance

ICD-10-PCS Guidelines

  • CMS 2022 ICD-10 PCS webpage: (link)

ICD-10-CM Guidelines

  • CMS 2022 ICD-10-CM webpage: (link)
  • The CDC ICD-10-CM webpage: (link)

Beth Cobb

Breast Cancer Awareness - Did You Know?
Published on 


Did You Know?

Chances are you; a family member, close friend or acquaintance has been impacted by breast cancer. October is Breast Cancer Awareness Month. According to a World Health Organization (WHO) Breast Cancer Fact Sheet (link):

  • In 2020, globally 2.3 million women were diagnosed with breast cancer and there were 685,000 deaths,
  • At the end of 2020, there were 7.8 million women alive who were diagnosed with breast cancer in the last 5 years, making it the world’s most prevalent cancer,
  • There are more lost disability-adjusted life years (DALYs) by women to breast cancer globally than any other type of cancer,
  • Breast cancer occurs in every country of the world in women at any age after puberty but with increasing rates later in life,
  • Approximately 0.5-1% of breast cancers occur in men,
  • Improvements in survival began in the 1980’s in countries with early detection programs combined with different modes of treatment to eradicate invasive disease.
Why Should You Care?

Even though family history increases the risk of breast cancer, most women diagnosed with breast cancer have no known family history of the disease. Early detection of breast cancer allows for a higher chance of cure. Mammography is used to detect breast cancer and is one of many Preventative Services covered by Medicare.

“A WHO survey conducted in 2020 indicated that treatment for cancer had been disrupted in more than 40% of countries surveyed.” A related RealTime Medicare (RTMD) infographic, in this week’s newsletter, highlights the impact of the COVID-19 pandemic on the volume of Medicare Fee-for-Service beneficiaries undergoing screening mammography in RTMD’s footprint.

NCD 220.4 Mammograms

The CMS National Coverage Determination (NCD) 220.4 Mammograms (link) distinguishes the difference between diagnostic and screening mammography.

Diagnostic Mammography

A radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy - proven benign breast disease and includes a physician's interpretation of the results of the procedure. CMS covers this service if ordered by a Doctor of Medicine or Osteopathy in addition to the following conditions:

  • A patient has distinct signs and symptoms for which a mammogram is indicated,
  • A patient has a history of breast cancer, or
  • A patient is asymptomatic but, based on the patient’s history and other factors the physician considers significant, the physician’s judgment is that a mammogram is appropriate.
Screening Mammography

A radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer, and includes a physician’s interpretation of the results of the procedure. A screening mammography has limitations as it must be, at a minimum a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast. Routine screening includes:

  • Asymptomatic women 50 years and older, and
  • Asymptomatic women 40 years and older whose mothers or sisters have had the disease, is considered medically appropriate, but would not be covered for Medicare purposes.

Guidance for coding and billing for screening mammography is available in the MLN Educational Tool: Medicare Preventive Services (link).

What Should You Do?

Take the initiative to discuss having a screening mammogram with your health care provider. You can also check out the CDC’s webpage Find a Screening Program Near You (link) that highlights the CDC’s national Breast and Cervical Center Early Detection Program (MBCCEDP). This year marks the 30th Anniversary for this program that has provided women who have low incomes, uninsured, and underinsured women across the United States.

Beth Cobb

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